Aug 20 2020

Opening Schools During a Pandemic

This is the big question facing many countries, but especially the US – how do we reopen schools while still in the middle of a pandemic? This is a serious dilemma. The American Academy of Pediatrics urges that, especially younger children, have the opportunity for in-person learning.  This is important not only for their education but their socialization and development.

The other important variable here, however, is how susceptible are children to SARS-CoV-2 and the COVID-19 infection it causes? Early experience showed that children are less susceptible to getting the illness and when they are infected are less likely to have serious disease. This partly informed the AAP’s recommendation. However – more recent data is casting doubt on the notion that children can safely return to school.

The most comprehensive review of the data so far, just published, shows that children are asymptomatic carriers of the virus, and have high viral loads, which means they can be very contagious. Further, when they do get symptoms they are likely to be more like cold symptoms, with a fever and runny nose, which in adults makes it less likely they have COVID-19. These two factors mean that children have been widely underdiagnosed. Most testing programs are focusing on symptomatic individuals, and children get missed by such efforts.

The review also concludes that a small percentage of children can get a late-stage complication of COVID-19, even if the illness is mild or asymptomatic – their immune reaction several weeks after infection can cause serious illness, including heart disease. This is one of the serious features of this illness, the immune system’s response can sometimes be severe, causing much more damage than the infection itself.

All of the implications of this new review are bad. First – children can be asymptomatic carriers of high viral loads of SARS-CoV-2. This is a setup for schools being petri-dishes to further spread this pandemic and bring the virus home to adult family members. We are right at the beginning of the Fall semester, with schools opening up now through early September. It’s hard to imagine we won’t be seeing a bump or even a surge in COVID-19 cases in a few weeks, and many worry that schools will be shutting down soon after reopening.

Schools are doing their best with the resources they have to limit the spread of any infection – reducing the number of students at school at any one time, mandating mask-wearing, social distancing, and practicing hand washing and other sanitary strategies. This is all good, but we simply don’t know if it will be enough – especially for younger children, who will find compliance more challenging.

Second, our children are not safe from this virus. Even though most will have few or no symptoms, some will get COVID-19, and some will get late serious complications. No parent wants to roll those dice.

And finally, there are implications for any vaccines in development. Again – in many cases the worst part of COVID-19 is not the infection itself but the body’s immune response to it. This means that an immune response to a vaccine may also have unintended consequences.  These negative reactions may also happen only in a small subset of people, and so may be missed by early safety screening. This means that we cannot skip any research steps in developing a COVID-19 vaccine. We need to do careful safety testing. We also cannot only test the vaccine in adults and then give it to children – their immune systems may respond differently. We need to test it in children. Even after approval, when we roll out the vaccine we will have to carefully monitor the results.

Keep in mind we have been aware of this virus and COVID-19 for less than a year. There is still a lot we don’t know about it, and the learning curve is still steep. It is amazing, in fact, that we have learned as much as we have as quickly as we have. This is a testament to the aggressive scientific research we have done so far. But our incomplete knowledge makes policy decisions difficult. We can take the cautious approach, and in most cases this is the best path. But when it comes to schooling, there is a significant downside to shutting down schools indefinitely (similar to shutting down our economy).

What this means is that we need to focus on strategies to educate our children without worsening this pandemic and exposing them to potential harm. During this pandemic we have had to learn and adapt many new strategies – for shopping, eating out, having meetings, having social engagement, treating patients, and other basic activities. Education should be at the top of the list.

Also, now is a good time for everyone to prepare for a potential second wave of this pandemic. Some experts are recommending that we (in the US) just shut down again, and this time do it right. We may be forced to do it anyway after the school surge hits.

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